ASSESSMENT

CARDIAC SYSTEM

By: Esperancita A. Ferrer RN

MD
HEALTH HISTORY AND
CLINICAL
MANIFESTATIONS
HEALTH HISTORY
 Include subjective information
 Biographic and demographic data
– age, gender, and ethnic origin
 Current health
– Height, current weight, and usual weight

CHIEF COMPLAINT
Is the reason why the patient came to the
hospital. It should be recorded in quotation
marks exactly as stated. ( e.g. “Shortness of
breath for 1 week”)
 Cardiac Signs and
Symptoms:
 Chest pain or discomfort (angina pectoris,
MI, VHD)
 Shortness of breath or dyspnea (MI,LVF, HF)
 Edema and weight gain (RVF, HF)
 Palpitations (dysrhythmias resulting from
myocardial ischemia, VHD, ventricular
aneurysm, stress, electrolyte imbalance)
 Fatigue (earliest symptom associated with
several CVS disorder)
 Dizziness and syncope or loss of
consciousness (postural hypotension,
dysrhythmias, vasovagal effect,
cerebrovascular disorders)
Points to remember
when assessing
patients with cardiac
symptoms
 Women present with atypical symptoms
 Elderly people and those with diabetes may
not have pain with angina or MI because of
neuropathies. Fatigue and shortness of breath
predominant symptoms.
 Patient may have more than one clinical
condition occurring simultaneously.
 Patient with a history of CAD, the chest
discomfort should be assumed to be secondary
to ischemia
HISTORY OF PRESENT
ILLNESS
 Onset
 Character
 Severity
 Location
 Duration
 Frequency of signs and symptoms
 Associated complaints
 Precipitating, aggravating, and relieving
factors
 Progression, remission, and exacerbation
Note:
When taking HPI be guided with
the questions in Table 26-3 •
Asking Questions to Evaluate
Cardiac Problems
 Past Health History
– Risk factors
– Major illness and surgical history
– Allergies
– Medications
– Dietary habits
– Childhood and infectious diseases
– Past illnesses
 Family History
– Genetic abnormalities associated
with cardiovascular disorders. E.g.
Familial Hypercholesterolemia
 Psychosocial History
– Status
– Number of children
– Occupation
– Hobbies
– Self-perception and self-concept
– Coping and stress tolerance
 Evaluate the following:
1. Effectiveness of the heart as a
pump
If there is presence of the following:
Cardiac insufficiency
– Reduced pulse pressure
– Cardiac enlargement
– Murmurs
– Gallop rhythms
2. Filling volumes and pressures
are estimated by:
– degree of jugular vein distention
– presence or absence of congestion in the
lungs
– peripheral edema
– postural changes in BP
3. Cardiac output
-reflected
cognition by:
- pulse pressure - texture of the
- heart rate – color skin
- urine output
4. Compensatory mechanisms
help maintain cardiac output
- increased filling volumes
- elevated heart rate
PHYSICAL
ASSESSMENT
(1) general appearance
(2) cognition
(3) skin
(4) BP
(5) arterial pulses
(6) jugular venous pulsations and
pressures
(7) heart
(8) extremities
(9) lungs
(10) abdomen
General Appearance
and Cognition
 Level of distress
 Level of consciousness
 Thought processes
Inspection of the Skin
Common findings associated with CVS disease:
 Pallor (a decrease in the color of the skin)
– lack of oxyhemoglobin.
– best observed around the fingernails, lips, and oral
mucosa.
– In patients with dark skin, nurse observes the palms
of the hands and soles of the feet.
 Peripheral cyanosis (bluish tinge)
– Suggests a decreased flow rate of blood to a
particular area
– Observed in the nails, skin of the nose, lips,
earlobes, and extremities
 Central cyanosis
– Venous blood passes through the
pulmonary circulation without being
oxygenated
– Observed in the tongue and buccal mucosa
– Indication of: pulmonary edema and
congenital heart disease
 Xanthelasma (yellowish, slightly raised
plaques in the Skin)
– observed nasal portion of one or both
eyelids
– Indicate hypercholesterolemia
 Reduced skin turgor
– occurs with dehydration and aging
 Cold and clammy
– In acute MI, diaphoresis is common.
 Ecchymosis (bruise)
– Patients receiving anticoagulant
therapy should be carefully observed
for unexplained ecchymosis.
– Excessive bruising indicates prolonged
clotting times (PTT & PT)
Blood Pressure
 Systemic arterial BP is the
pressure exerted on the walls of
the arteries during ventricular
systole and diastole.
 Expressed as the ratio of the
systolic pressure over the
diastolic pressure
Seventh Joint National Committee
Classification
Hypertension Systolic (mmHg) Diastolic
(mmHg)

Category
Normal <120 and <80
Prehypertension 120 – 139 or 80 – 89
Hypertension
Stage 1 (mild) 140 – 159 or 90 – 99
Stage 2
(moderate-
severe) >160 or > 100
 PULSE PRESSURE
Difference between the systolic & diastolic pressure
Normal:30 to 40 mm Hg
When is Pulse Pressure increased or decreased?

Increased Pulse Decreased Pulse

Pressure Pressure
1. ↑ SV (anxiety, 1. ↓ SV & ejection velocity
exercise, bradycardia) (shock, HF, hypovolemia,
2. ↓ SVR (fever) mitral regurgitation)
3. ↓ distensibility of the 2. obstruction to blood
arteries flow during systole
(atherosclerosis, aging, (mitral or aortic stenosis)
HPN) Pulse pressure of <30
POSTURAL BLOOD PRESSURE CHANGES
Postural (orthostatic) hypotension
- There is a postural decrease from the supine to
standing position of at least 20 mmHg in systolic or 10
mmHg in diastolic BP sustained for at least 3 min
- S/Sx: dizziness, lightheadedness, or syncope.

Most common cause:

1. Due to an Autonomic Dysfunction.
2. Due to a reduced volume of blood in the circulatory
system (e.g., intravascular volume depletion,
dehydration)
3. Due to inadequate vasoconstrictor mechanism
 Arterial Pulses

Factors to be evaluated:
1. Rate
2. Rhythm
3. Quality
4. Configuration of the pulse wave
5. Quality of the arterial vessel
PULSE RATE
Normal 60-100bpm
In healthy young athletes 50 bpm
PULSE RHYTHM
Regular or irregular
Sinus arrhythmia in young individuals is
normal. ↑PR in inhalation ↓PR in exhalation
Note:
 In initial cardiac examination: HR should be
counted by auscultating the apical pulse
for a full minute while simultaneously
palpating the radial pulse
PULSE QUALITY
assessed bilaterally
Scales can be used to rate the strength of the pulse:
0 pulse not palpable or absent
+1 weak, thready pulse; difficult to palpate;
obliterated with pressure
+2 diminished pulse; cannot be obliterated
+3 easy to palpate, full pulse; cannot be
obliterated
+4 strong, bounding pulse; may be abnormal
PULSE CONFIGURATION
 Best appreciated by palpating the carotid artery.

In conditions such as:

1. Aortic stenosis:
stenosis pulse pressure is narrow, and
the pulse feels feeble
2. Aortic insufficiency:
insufficiency rise of the pulse wave is
abrupt and strong, and its fall is precipitous—a
“collapsing” or “water hammer” pulse.
EFFECT OF VESSEL QUALITY ON PULSE
 Assessment of the quality of the vessel by
palpating along the radial artery and comparing it
with normal vessels.
 Arteries in the extremities are often palpated
simultaneously
 Jugular Venous

Pulsations
An estimate of right-sided heart function. This
provides a means of estimating central venous
pressure (CVP)
CVP
 CVP reflects right atrial or right ventricular end-
diastolic pressure (the pressure immediately
preceding the contraction of the right ventricle).
 Normally: Jugular veins are distended when
supine once HOB is elevated to 30 degrees it
disappears
 Abnormal: Jugular veins distended when patient’s
head elevated 45 degrees to 90 degrees. An
indication of right-sided HF
HEART
Inspection & Palpation
 In adult heart lies behind & to the left of the
sternum. A small portion of the right atrium
extends to the right of the sternum.
 The heart lies in a rotated position within the

chest cavity, the right ventricle lies anteriorly

(just beneath the sternum) and the left
ventricle is situated posteriorly.
posteriorly
BASE- Both atria; lies toward the back
APEX- ventricles; points anteriorly
 Apex of left ventricle touches the wall or 5th

ICS LMCL, (below left nipple). This area is

called PMI
Precordium
The area on the anterior chest
overlying the heart
Correct position for examination
of the precordium
What to observe for?
 LIFT or HEAVE appears to lift the hand from
the chest wall during palpation A broad or
forceful apical impulse.
 Enlargement of LV- heave lateral to the
apex
 Enlargement of RV- heave at or near
sternum
 THRILL abnormal, turbulent blood flow
within the heart may be palpated with the
palm of the hand as a purring sensation.
 Chest Percussion
 Purpose: To detect enlargement of the
heart to either the left or right
 Only the left border of the heart can
be detected by percussion.
 It extends from the sternum to the
MCL in the 3rd to 5th ICS.
 Cardiac Auscultation
- Mitral - Aortic
Tricuspid Pulmonic
ATRIOVENTRICULAR VALVES: AVV
Separate atrium & ventricles
Tricuspid Valve & Mitral Valve
SEMILUNAR VALVES: SLV
The valve between right ventricle & pulmonary
artery- Pulmonic Valve
The valve between left ventricle & the aorta-
Aortic Valve

SYSTOLE AVV close DIASTOLE AVV open

SLV open SLV close
S1 S2
lub dub
 Heart Sounds
S1—First Heart Sound.
– Closure of the mitral and
tricuspid valves
– is heard best at the apex
of the heart (apical area)
S2—Second Heart Sound.
– Closing of the aortic and
pulmonic valves
– heard loudest at the base
of the heart.
S1 & S2 are Normal Heart
Sounds
S3-Third Heart Sound
– Gallop sounds
– occur early in diastole during rapid ventricular filling
– Normal in children and young adults
– Abnormal finding in CHF
– heard best with the patient lying on the left side
S4-Fourth Heart Sound
– Gallop sounds heard during atrial contraction
– heard when the ventricle is enlarged or hypertrophied and
therefore resistant to filling
– Abnormal finding in HPN, Aortic valve Stenosis, CAD
Note:
 Gallop sounds are low-frequency sounds heard only with the
bell of the stethoscope placed very lightly against the chest.
 They are heard best at the apex
 Snaps and Clicks.
– SNAP: Stenosis of the mitral valve resulting from RHD
gives rise to a unusual high-pitched sound heard best
along the left sternal border.
– EJECTION CLICK: Stenosis of the aortic valve gives rise to
a short, high-pitched sound immediately after S1
 Murmurs
– are created by the turbulent flow of blood.
Caused by:
1. narrowed valve
2. a malfunctioning valve that allows regurgitant blood flow
3. congenital defect of the ventricular wall
4. a defect between the aorta and the pulmonary artery
5. an increased flow of blood through a normal structure
 Friction Rub.
– a harsh, grating sound that can be heard
in both systole and diastole.
– Seen in Pericarditis.
Pericarditis
– heard best using the diaphragm of the
stethoscope, with the patient sitting up
and leaning forward.
 Inspection of the
Extremities
 Observe for skin and vascular changes:

1. ↓ capillary refill time

2. Vascular changes: ↓ in quality or loss of
pulse, discomfort or pain, paresthesia,
numbness, ↓ in temperature, pallor, & loss
of movement.
3. Hematoma-localized
Hematoma collection of clotted
blood in the tissue
4. Peripheral edema is fluid
accumulation in dependent areas of
the body.
Seen in HF or DVT or Chronic Venous
Insufficiency
5. Clubbing of the fingers and toes
implies chronic Hgb desaturation.
Seen in congenital heart disease.
disease
6. Lower extremity ulcers are observed
in patients with arterial or venous
insufficiency.
LUNGS
Findings frequently exhibited by cardiac
patients include the following:
1. Tachypnea
– Rapid, shallow breathing. Seen in HF
2. Cheyne-Stokes respirations
– rapid respirations alternating with apnea.
Seen in LVF
3. Hemoptysis
– Pink, frothy sputum is indicative of acute
pulmonary edema.
edema
4. Dry, hacking cough
– irritation of small airways is common in
patients with pulmonary congestion from
HF.
HF
5. Crackles
– discrete, noncontinuous sounds that result
from delayed reopening of deflated
airways
– Heard in HF
6. Wheezes
– Compression of the small airways by
interstitial pulmonary edema
ABDOMEN
What to assess for?
1. Hepatojugular reflux:
 Procedure: pressing firmly over the RUQ of the
abdomen for 30 to 60 seconds and noting a rise of 1
cm or more in jugular venous pressure.
 Liver engorgement occurs because of decreased
venous return secondary to RVF.
2. Bladder distention:
 Procedure: palpate for an oval mass and percuss for
dullness
 Urine output is an important indicator of cardiac
function, especially when urine output is reduced.
 This may indicate inadequate renal perfusion
AEF 01-23-09